Every finding on record at Good Shepherd Lutheran Home of Sauk Rapids, Mn

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/9/24-4/11/24, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 4/9/24 through 4/11/24 a recertification survey was conducted. This resulted in a partial extended survey at Good Shepherd Home Health Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 164 Total home visits conducted: 3 List Parent Location visited, including the addresses as verified while on site: 1115 Fourth Ave N Sauk Rapids, MN 56379 List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from: None List Hours of Operation: 8:00 a.m. to 4:30 p.m. List total number of records reviewed: 7

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure medication regimen review, and reconciliation of medications, was completed to ensure the medications on the plan of care (POC) were available, and were set up as ordered by the provider, for 1 of 3 (P3) patients observed during the home care visits. P3's Home Health Certification and POC for certification period of 2/23/24 to 4/22/24, indicated P3's primary diagnosis was hemiplegia (a loss of the ability to move one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (stroke) affecting the left, non-dominant, side. P3's POC also indicated other diagnoses which included thrombocytopenia (a condition where abnormally low level of platelets was observed. Platelets are involved with clotting of the blood.), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), atherosclerotic heart disease (hardening of the arteries) of native coronary artery without angina pectoris (chest pain), urge incontinence, congenital hypothyroidism (underactive thyroid) insomnia, and cervicalgia (neck pain). P3's POC indicated he received skilled nurse services weekly for assessment of skin breakdown, level of pain, and of GI (gastrointestinal-digestive system) status. The nurse was also to observe for signs and symptoms of urinary tract infections and educate P3 on this. The plan of care directed the nurse to monitor for change in neurological/mental status and assess and evaluate functional limitations. The POC lacked orders for medication set up for P3. On 4/10/24, at 8:30 a.m. registered nurse (RN)-A was observed during home visit with P3. Upon the initiation of visit, patient assessment was completed which included vital signs (temperature, pulse, respirations, and blood pressure with P3). RN-A also completed a review of systems, which included bowel function which included an assessment of bowel sounds, and RN-A inquired of frequency of bowel movements, appetite, and any nausea was experienced. RN-A then assessed the respiratory and cardiac status (inquired of chest pain, shortness of breath, cough, or of any swelling of the ankles. A pain assessment was completed and P3 reported his level of pain was at a 2.75 on a scale of 0-10 (zero being no pain and the level of ten being excruciating/unbearable). P3 stated his back pain had improved, however, he continued to have low back pain. P3 reported he received personal therapy twice weekly. RN-A was observed as she completed medication set up, using the medication profile printed prior to visit, and proceeded to set up medications. P3's medications were set up in a removable tray, which was then inserted into a timed electronic medication dispenser. RN-A stated P3 also had a backup supply of one week in the home, which family would assist with in the event of an emergent or delayed visit at which time medication were unable to be set up. During the set-up of medications, the following discrepancies were noted: Calcium/Vitamin D tablet (600 mg/400 unit) one tablet daily for supplement was ordered and set up. A review of the prescription label indicated the medication was dispensed on 1/20/23, and was to be discarded after 1/19/24. Atorvastatin Calcium 20 mg was ordered at 10 mg (1/2 tablet) daily at bedtime was ordered and set up. A review of the prescription label indicated the prescription was dispensed on 1/6/23, and was to be discarded after 1/15/24. In addition to the above listed discrepancies, it was noted that although the following medications were listed under the section of the POC identified as Medications, RN-A failed to review availability of medications, and usage pattern, of the medications. Carbamide Peroxide Solution-Instill four drops to both ears every week for ear wax removal. The directions identified family manages, however, RN-A failed to inquire of effectiveness or ongoing use. Although bowel and digestive status were reviewed, the use of the following medications was not reviewed, and adequate supply was not assured. The following medications were ordered for bowel function: Sennosides Tab, 8.6 mg tablet was ordered as one to two tablets once daily as needed for constipation. P3 stated he had not used this medication and lacked a current supply. Bisacodyl Suppository, 10 mg one suppository as needed daily for constipation. P3 stated he had not used this and lacked a current supply. Polyethylene Glycol Powder, 17 grams with four to six ounces of liquid in the morning and at bedtime as needed for constipation. P3 stated he used this medication twice a day routinely and it was effective for bowel management. During the initial assessment, RN-A inquired of current pain status, as well as current therapy and exercise regime, however, failed to review the following medications: Lidocaine TDM, 5 % one patch daily as needed for pain. The directions directed P3 to leave on for up to 12 hours, and remove. The directions directed P3 to wait at least 12 hours before applying a new patch. P3 stated he has not used recently, and showed RN-A large supply of patches present. Bio Freeze gel 4%, as needed for pain. RN-A lacked review of usage pattern and availability of medication. Acetaminophen tablets, 325 mg tablets, two tablets every four hours as needed for pain. Following review of medications between RN-A and P3 clarification was requested by surveyor. P3 stated he used Tylenol 8HR Arthritis Pain, two tablets, twice a day, and reported this worked well. An open bottle of Tylenol 8HR Arthritis Pain medication was noted on the kitchen counter. The dosage of the medication was observed to be 650 mg, and the bottle contained 290 tablets. P3 reported he had used one bottle of this brand already and was partially into the second bottle. P3 stated he always keeps his Tylenol on the counter above the dishwasher. RN-A stated she had not noticed this brand of acetaminophen before. RN-A reviewed the dose of acetaminophen with P3, and explained to P3 he was currently taking 1300 mg twice daily. RN-A informed P3 the dose of medication ordered by provider was two tablets of 325 mg for a total of 650 mg every four as needed for pain. RN-A informed P3 she was going to follow up with the provider regarding both the current, and desired dose. Following the home visit, at 9:30 a.m. RN-A stated family members were responsible for ordering the medication for the patient. RN-A stated it was by the direction of the family the medication was to "used up" and not discarded. RN-A stated the recommendation was not to use after one year, or as identified on the "Discard After" date on the label, however, based on family direction, she had used the medication. RN-A stated meds were to be reviewed and reconciled with every medication set up, visit, and with recertification. On 4/10/24, at 1:32 p.m. the Director of Home Care Services stated medications should be reviewed with every visit, including medication set up. If a family member requested medications were to be used after the date they have expired or were to have been discarded, the family member should have been advised of the policy of the agency, and medications should not have been used for medication set up. A review of the facility policy, Drug Regimen Review, revised 8/2019, identified upon admission, a comprehensive assessment was to be completed at the time of admission and was to include Drug Regimen Review. The Drug Regimen Review was to include a review to identify any potential adverse effects and drug reactions, ineffective drug therapy, significant side effects or drug interactions, duplicate drug therapy, and noncompliance with drug therapy. In addition to the components listed, the nurse was to review with the patient the use of the medications to ensure their understanding which was to include storage and administration of medication, purpose of the medication and potential side effects, as well as effectiveness and appropriateness.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to secure physician orders for 1 of 1 resident, (P3), who was observed for medication management. P3's Home Health Certification and Plan of Care (POC) for certification period of 2/23/24 to 4/22/24, indicated P3's primary diagnosis was hemiplegia (a loss of the ability to move one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (stroke) affecting the left non-dominant side. P3's POC also indicated other diagnoses which included thrombocytopenia (a condition where abnormally low level of platelets was observed. Platelets are involved with clotting of the blood.), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), atherosclerotic heart disease (hardening of the arteries) of native coronary artery without angina pectoris (chest pain), urge incontinence, congenital hypothyroidism (underactive thyroid) insomnia, and cervicalgia (neck pain). P3's POC indicated he received skilled nurse services weekly for assessment of skin breakdown, level of pain, and of GI (gastrointestinal-digestive system) status. The nurse was also to observe for signs and symptoms of urinary tract infections and educate P3 on this. The plan of care directed the nurse to monitor for change in neurological/mental status and assess and evaluate functional limitations. P3's orders for skilled nursing services lacked indication of medication set up for patient. On 4/10/24, at 8:30 a.m. registered nurse (RN)-A was observed during home visit with P3. Upon the initiation of visit, patient assessment was completed which included vital signs (temperature, pulse, respirations, and blood pressure with P3). RN-A also completed a review of systems, which included bowel function which included an assessment of bowel sounds, and RN-A inquired of frequency of bowel movements, appetite, and any nausea was experienced. RN-A then assessed the respiratory and cardiac status (inquired of chest pain, shortness of breath, cough, or of any swelling of the ankles. A pain assessment was completed and P3 reported his level of pain was at a 2.75 on a scale of 0-10 (zero being no pain and the level of ten being excruciating/unbearable). P3 stated his back pain had improved, however, he continued to have low back pain. P3 reported he received personal therapy twice weekly. RN-A was then observed as she completed medication set up, using the medication profile printed prior to visit, and proceeded to set up medications, which were inserted into the timed electronic medication dispenser. During a follow up interview on 4/10/24, at 9:30 a.m., RN-A stated previously the medications had been set up and managed by the Assisted Living (AL) where the patient resided. RN-A stated P3 began with med set up by the agency approximately one to two months ago. RN-A stated they had been following P3 for skilled nursing visits, and family had requested that they begin med set up. RN-A stated she had not realized the order for medication set up had not been added to the orders for care. RN-A stated she was unsure of the exact date these services had been initiated. Upon review of skilled nursing visit notes, it was identified in the visit note of 1/17/24 "Family requesting that homecare take over the medication set up. Met with AL nurses this morning and meds are now in client's apt [apartment]." During interview on 4/10/24, at 1:32 p.m., the Director of Home Care Services stated upon review of the narrative documentation, the services for medication set up was initiated on 1/17/24. The Director stated an order for medication set up was required before initiated. Upon review of the most recent POC, it was identified although initiated on 1/17/24, it was also not included with orders from the most recent recertification of 2/23/24 to 4/22/24. A review of the facility policy, Medication Set Up, revised 5/2016 identified the process of the medication set up, however, lacked indication orders must be received from a provider prior to initiating medication set up. The agency policy, Physician's Orders, revised 12/2023, identified medications and treatments must be administered by a nurse or therapist qualified to perform the order. The policy outlined upon receipt, all applicable orders will be entered into appropriate computer system and/or placed on the client record.

On July 20, 2021 through July 22, 2021, a survey for compliance with Appendix Z, Emergency Preparedness Requirements, §483.73(b)(6) was conducted during a standard recertification survey. The facility was IN compliance.

A partial extended survey was conducted at Good Sheppard Home Health Care July 20th, 21st and 22nd 2021. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. BRANCH OFFICES: None Unduplicated census 155 NUMBER OF HOME VISITS MADE: 3 NUMBER OF RECORDS REVIEWED: 07 HOURS OF OPERATION: 8:00 a.m. to 4:30 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and document review, the agency failed to complete a comprehensive medication review during a home visit to ensure medication profiles were accurate for 1 of 3 patients (P5) observed during home visits. Findings Include: P5's face sheet undated, indicated diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter for type two diabetes mellitus with diabetic nephropathy, chronic diastolic (congestive) heart failure, dementia in other diseases classified elsewhere without behavioral disturbance. P5's Plan of Care (POC) dated 6/21/21 to 8/19/21 indicated a start of care (SOC) dated 6/21/21, indicated Drug regimen review: did a complete drug regimen review identify potential clinically significant medication issues, clinical manager (CM)- B indicated No- No issues found during review. P5's 485 (plan of care) dated 6/21/21 to 8/19/21 indicated the following; 1) Zytrec (medication for allergies) 10 take one tablet daily as needed for 75 days in the summertime. 2) Oxycodone (narcotic pain medication) 5 mg take one tablet as needed every 4 hours for moderate pain. 3) Proventil (inhaler for shortness of breath) 90 mcg, (2 puffs) administer 2 puffs as needed every 4 hours for shortness of breath, cough, or with exercise). 4) fish oil (supplement) 340, 1000 micrograms. Take 1 capsule daily. 5) Minoxidil (helps lower blood pressure) 10 mg take one tablet daily for hypertension. 6) metoprolol (blood pressure medication) 100 mg take 200 mg twice daily, give with food. 7) levothyroxine (thyroid medication) 50 micrograms take one tablet daily. No indication on plan of care for 8) Sertraline (antidepressant) 100 mg take 1 tablet by mouth once daily for depression. 9) Doxyclinine monohydrate (antibiotic) 100 mg take one capsule daily (no end date). 10) Vitamin C (supplement) 1,000 mg by mouth once daily. 11) Vitamin D3 2,000 units take 2,000 units once daily. 12) acetaminophen 500 mg take one to two tablets by mouth every four to six hours as needed. During home visit on 7/21/21, at 10:00 a.m. to observe physical therapy assistant. Medication review with family member (FM)-A along with comparing to bottles. FM-A stated the following 1) Zyrtec has not been used in years, 2) Oxycodone has not been used since he left the hospital and before starting home care. 3) Proventil has not been used in years. 4) Fish oil I give P5 1 capsule twice daily and have been doing this since before surgery. 5) Minoxidil bottle indicated 10 mg tablets take one and one-half tablets by mouth daily. bottle filled on 4/1/21. 6) Metoprolol bottle indicated 100 mg, take 1 tablet by mouth once daily. FM-A stated he has been doing this for a long time. 7)Levothyroxine bottle indicated 112 mcg. Take one tablet daily. FM-A stated he has been on this dose for at least a year. 8) Sertraline bottle 100 mg take 1 tablet by mouth once daily. FM-A stated he has been on this for years as well. 9)Doxycycline 100 mg FM-A stated he is no longer taking this as it was completed on 7/16/21. 10) Vitamin C FM-A stated P5 has not taken this in years as well and drinks a glass of juice every morning to get his vitamin C. 11) Vitamin D3 bottle was for 5,000 international units (IU). FM-A stated she gives it to him four times a week to even it out to be about 2,000 IU daily and has been doing this since before starting homecare. Bottle of Vitamin D3 almost empty. 12) Acetaminophen 500 mg FM-A stated he takes two tablets by mouth twice daily for pain which has been scheduled since leaving the hospital. 13) FM-A stated she started P5 back on Aspirin 81 mg daily per physician orders. During interview on 7/21/21, at 9:40 a.m. FM-A stated that when CM-B came out to complete the start of care for P5 after returning from hospital, CM-B did sit down and go through medications with her, however they did not compare them to the bottle labels for dosing. During interview on 7/21/21, at 1:35 p.m. CM-B stated she did not recall going over the bottles with FM-A regarding P5's medication, but did recall that they went over with a sheet of paper that FM-A had. CM-B stated that FM-A handles P5's medications. CM-B stated that it was important to go over both the medications and the bottles to make sure P5 was getting the correct medications and dosages. CM-B was given the clarifications after visit and compared with discharged medications and stated she checked off all the medication that were from the discharge summary but was not sure why the medications on the plan of care was different from the bottles. CM-B indicated she enters the medications herself and was unsure how this could happen, but indicated it was a concern. During interview on 7/21/21, at 3:45 pm CM-C stated that the plan of care should include accurate medications list that the provider ordered and that the plan of care along with the medication list is how they know what medications are to either be set up for the client or the clients takes on their own. CM-C stated if the medications are wrong on the care plan the client could be given the wrong medication and that would not be good. During interview on 7/21/21, at 3:56 p.m. CM-A stated the plan of care is used to direct staff on what medications or treatments are to be completed with each client. CM-A stated that during the start of care the registered nurse is to go over both the clients medication list along with the discharge summary and the medication bottles to compare the lists to completed the medication reconciliation. CM-A stated if there were any errors or clarification needed the nurse would notify the physician. CM-A stated it was important for the plan of care to be accurate to ensure the client was getting the correct medications. CM-A further stated that the plan of care are the orders that the nurses are to follow when caring for the clients. CM-A stated that with P5's medications being incorrect that it was not ok and the nurse should have compared the bottles to the discharge summary and notify the provider if the client was taking differently. CM-A stated she was unsure how the medications were not completed correctly and will be corrected immediately. During interview on 7/22/21, at 8:30 am CM-A stated that she found out how the medication were entered incorrectly as P5 had a previous admission years ago and those orders pulled through. CM-A stated that CM-B went out to P5's home and attempted to do a start of care and went through the medications with P5 and FM-A but ended up not opening client as he was sent in due to extreme pain in his surgical hip. CM-A stated CM-B went back out on 6/21/21 to reopen client post hospital stay and thought that those medications from previous visit would have pulled through as she had already completed the reconciliation of medication. CM-A stated that the attempted start of care was canceled and therefore the medications would have not been pulled through. Drug Regimen Review policy revised on 8/2019, indicated "upon admission, a comprehensive assessment of the client will be completed. This assessment will include drug regimen review. All medication the client is currently taken will be reviewed to : identify any potential adverse effects and drug reactions, identify ineffective drug therapy, identify significant side effects, identify significant drug interactions, identify duplicate drug therapy, identify noncompliance with drug therapy. The nurse shall record on the client's record all prescribed and over the counter medications". Nursing Admission policy revised 2/2020, indicated "the RN will complete an individualized comprehensive assessment of the client". Comprehensive assessment policy created 9/2018, indicated "a comprehensive review and history of prescribed, over-the-counter medications and herbal supplements, including (client medication information and reconciliation): potential/actual drug interaction, ineffective drug therapy, food and drug interactions, drug allergies and sensitivities, past medication compliance, duplicative drug therapy, potential and past adverse effects, signification side effects, noncompliance with drug therapy".

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure communication with the physician for 1 of 7 clients (P5) when a missed visit occurred. Findings include: P5's face sheet undated, indicated diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter for close, type two diabetes mellitus with diabetic nephropathy, chronic diastolic (congestive) heart failure, dementia in other diseases classified elsewhere without behavioral disturbance. P5's plan of care (POC) dated 6/21/21 to 8/19/21, indicated physical therapy (PT) was to see client three times during the week of June 27th to July 3rd. P5's Patient Information Sheet undated, indicated Physical therapy visits scheduled for 6/28/21, 6/30/21, and 7/1/21. P5's Patient Information Sheet undated, indicated physical therapy visits that actually occurred was 6/28/21 and 7/1/21. P5's Record review of missed visit/physician notification did not show any missed visit notifications to the primary provider. During interview on 7/21/21, at 10:47 a.m. physical therapy assistant (PTA)-A stated that when he calls in he will notify the office and not sure if the office notifies the provider or not. PTA-A stated he did not notify the provider of any missed visits. During interview on 7/21/21, at 1:00 p.m. clinical manager (CM)-B stated with any missed visit it should be entered into the computer so the provider gets notified. CM-B stated visits are part of the order and we are to follow physician orders. During interview on 7/21/21, at 3:45 p.m. CM-C stated any missed visit should be marked as missed and the provider should be notified as it is important to follow provider orders. During interview on 7/21/21, at 3:56 p.m. CM-A stated and confirmed that the week of June 28th to July 3rd 2021 client was only seen twice that week and should have been seen three times. CM-A confirmed that no missed visit and notification to provider had occurred. CM-A stated it was important to follow provider orders and that the provider should be notified with any missed visit. Missed visit policy revised 8/2015, indicated "The plan of care developed in consultation with the agency staff and client must remain congruent with the services provided. All visits ordered by primary physician are completed according to the physician's plan of care. In the event an ordered visit is not completed according to the physicians plan of care documentation will be placed in the medical record and sent to the primary physician".